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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F.i:0�FCli t�SE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. D <br /> THIS PERMIT EXPIRES 1. YEAR FROM.DATE ISSUED Date Issued <br /> I <br /> {Complete In Triplicate) <br /> Application is hereby rude to the San Joaquin Local Health District for a permit to construct <br /> and/or in the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No, 1.862 and the Rules and Regulations of the San 3oaq J����H�l th �e ct. <br /> JOB ADDRESS/LOCATION _ fv CENSUS TRACT <br /> Owner's Name ry �� Phone C� <br /> Cit <br /> Address <br /> Contractor's Name License # 6L a hone 7-!Q 23CY! <br /> TYPE OF WORK (Check) : NEW WELL .IGS DEEPEN I I RECONDITION I / DESTRUCTION ,/� <br /> � <br /> PUMP INSTALLATION /l./--PUFF REPAIR-/�'/, PUMP REPLACEMENT / <br /> o er <br /> th <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK� EWER LINES �j IT PRIVY <br /> SEWAGE DISPOSAL FIELD " ,5 A SSPOOL/SEEPAGE PIT QUx—OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> l I stxial Cable-Tool' " ""Dia: of Well Excavation <br /> Dia. of Well Casing / <br /> Domestic/private DrilleDriven/ Gauge of Casing <br /> Domestic/public <br /> Irrigation � �Gravel Pack Depth of Grout S�al1 � 40, <br /> k Other !/ RoLary :.Type of Grout_ oAr�1�7�� --- <br /> Other < Other Information <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of P <br /> Aiii <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP 'tEPAIR: / / State work Done <br /> } Approximate Depth <br /> ,DFIZTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> ,I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> =`and the State of California pertaining to or regulating well"construction. Within FIFTEEN DAYS <br /> after completion of my work on a neer well, I will furnish .the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putiting the well in use. The above <br /> in rmation is true to bes owledge and belief. <br /> WL TITLE <br /> SIGNED <br /> W PLOT PLAN ON REVERSE SIDE) <br /> .r- FOR DEPARTMENT USE ONLY F y <br /> t•�f Pl E I DATE <br /> } r1PPI,I CEPTEI) .BY <br /> I ADDITIONAL COMMENTS: PHA IIT./FINAL INSPECTION <br /> r PHA X11 GROUT INSPECTION DATE <br /> INSPECTION BY DATE` -/�`! INSPECTION BY <br /> s CALL FOR A GROUT INSPECTION PRIOR T07dROUTIk'AND FINAL INSPECTION. <br /> s ti 5/731M - <br /> V u 7 A 9( 4 _.-. <br />